White Ravens. Christer Mjåset. Gyldendal Agency. Sample translated by Deborah Dawkin

Transcription

1 Gyldendal Agency. White Ravens By Christer Mjåset Sample translated by Deborah Dawkin Mathias kicked open the door to Operating Theatre 12 and went in with his newly washed hands held out in front of him. He stopped in the middle of the room and tried to gather his thoughts. He would have preferred to be anywhere right now, rather than here in Haukeland Hospital, and more than anything he would have preferred not to be the duty surgeon in the Neurosurgery Department with all the responsibility that this placed on his shoulders. He had no idea whether he was capable of taking this on. He registered that the operating nurse was walking towards him and that she opened her mouth to say something, but her words turned to a jumble in his head. He took a deep breath and tried to concentrate. What did you say? Your glove size? What is it? Seven and a half. The nurse nodded like a monk and then glided past him without another word. He bent over the open parcel containing his surgical gown. His hands were shaking as he grabbed the gown with both hands and shook out its folds. As he stuck his hands in the arms of the robe, the thought of all the things that could go wrong raced through his head; like a TV cavalcade of doctor s blunders, with himself in the lead role. He knew he had to stop thinking like this, but it didn t help. The pictures forced themselves in on him, however much he tried to fight it. He shuddered as someone took his surgical gown and fastened the Velcro at the back. He looked at the clock over the door as he waited for his gloves to arrive. It was already four o clock. The middle of the night. A couple of hours ago he had been lying in a deep sleep, without a care in the world. And now he was suddenly here, watching his own hour of destiny unfold. Because this was nothing less. The patient on the table was a young boy in his early twenties with an intracranial haemorrhage which Mathias had to stop. And it didn t help his nerves exactly, that this was the first time he would open a cranium alone. Look, Grande! It was Edith s voice; the operating nurse who would stand at his side in the sterile zone. She was holding a glove up in front of him, so that all he had to do was slip his hand in. He did as she demanded, allowing himself a little smile under his mask, while a double glove was put on each hand. Edith was an old pro who knew all the operational procedures backwards. He could not have had a better assistant tonight. There!

2 Edith clapped her hands to signal her satisfaction. Mathias went towards the patient s head. It was covered with drapes on all sides. The half of the head that he had shaved and marked with the incision line, was all that was exposed. He put his hand on the smooth scalp and felt his heart begin to beat even harder. It was as though the whole room was pulsating. He looked down towards the foot of the table where the anaesthetist team were working at a frenzied tempo behind the vertical drape, which had been set up to divide the sterile from the unsterile areas. Have you given him mannitol? he said. Yes, said the anaesthetist without meeting his gaze. He seemed stressed, and with good reason. And keflin? That too. Right. Then we ll start. Mathias turned towards Edith and was about to ask for a scalpel but stopped himself, realising she was already holding one up for him. Listen, Grande, she said, so quietly that only he could hear. We ll manage this. We ll take one step at a time. Just make sure you talk clearly. OK? Mathias nodded. His whole body was trembling as he grasped the handle of the scalpel. He had never been so scared in all his life. More about the mistakes he might make perhaps, than what could happen to the patient. But he mustn t think like that. He had to start. It had been closer to half past two when he first got the call. There had been a fight at a party out on the Sotra islands, and a young boy had been found unconscious. The boy had been flown in by helicopter, and the trauma team had been standing by at the hospital to receive him when he was wheeled in. Soon Mathias was in the control room in the CT-suite and staring at cross sectional images as they rolled across the computer screen. The white mass that had spread between the inside of the cranium and the left side of the brain, could not be mistaken. A large collection of blood was pressing against the brain, so that its midline had shifted several centimetres to the right. If this blood wasn t removed quickly, the boy was going to die. That much was clear. He had immediately dialled the number of his surgical back up, Per Irgens. Irgens wasn t just anybody here at Haukeland Hospital. He had led the department since 1980, but had, in the last few years, handed the helm over to others. Despite being near retirement age, he insisted on being on call. For those who knew him, this was not very surprising. He still got intense satisfaction from challenging himself, and had the urge to push himself to the fore, more associated with a man in his early twenties. Irgens knew this about himself, and liked to tell stories that highlighted this. Everybody had heard what happened when he d torn a knee ligament in a bad fall in a 70m ski jump some years ago. Irgens had got up and jumped again. And this time he d stayed on his feet. When Mathias explained the situation to Irgens that night, he had expected a quick I m on my way. But instead the chief surgeon had gone quiet for a few moments, before coming up with his usual cryptic question: What s the most important muscle for a neurosurgeon? It was a question Mathias had heard innumerable times. Irgens always asked it when he wanted to put colleagues or students on the spot. He was not looking for the Latin name of some particular muscle, as many thought. He just wanted to point out that a neurosurgeon had to have a steady hand, and always remember that retreat could be as important as action. A great deal of damage could be done by blustering in. Mathias answered without having to think: The antagonist. I ve started to set up, and I ve opened a trauma case report. I hope that s OK?

3 There was silence again. Mathias wondered whether Irgens didn t realise the seriousness of the situation, and repeated the question. But then the surgeon answered at last, I think you can manage this on your own, Mathias. What do you mean? There was an irritated grunt at the other end. I mean what I say. There s got to be a first time, and you ll never feel ready. Just don t forget the antagonist. There was a click on the line before Mathias could say anything. Nonetheless he stood there with the receiver pressed to his ear. There was something growing inside him. Something resembling fear. The scull was now exposed. Mathias cleaned it with a swab. So far so good. He took hold of the craniotome and pressed the drill bit on the surface of the bone, where he had decided to make the hole. Edith had already started flushing the tip with water before he d even had time to press the foot pedal to start the drill rotating. White bone chips rose from the hole into which the drill disappeared. He didn t like these drills. They were designed to stop when they reached the other side of the cranial bone, but he never quite trusted them. Now, to his relief, a click in the tip signalled that the stopping mechanism had been released. He was about to tug the drill back out when he realised Edith s hands were already there. They did it together. I ll get the saw ready, she said. She passed him an Olivecrona wire saw and he used it to whisk out the last disk-like slices of bone at the bottom of the burr hole. Now, at last, he could look down at the blueish-white membrane that lay revealed. The dura mater the tough mother acted as a thick protective layer around the brain. He would have to get beneath this to remove the blood, but it was vital to stay this side of the dura as he sawed into the scull, so as not to risk tearing across any blood vessels or running into the brain tissue. Needless to say, that would spell disaster. Here! He looked up and the saw was immediately in his hands. He gripped its handle firmly and placed the thin blade into the hole that had been made by the craniotome. The tooth at end of the blade hooked neatly on the underside of the bone. Now all he had to think about was the antagonist. He pressed the pedal. The saw started up with a whine. The bone chips flew, and a stream of smoke rose from the incision as it was drawn across the cranium. He felt the metal getting hot under his glove despite Edith s attempts at cooling it with water. It was vital that he dare to make a large enough opening. If it was too small, he would not be able to get to all the blood that had accumulated on the cerebral cortex. He took his time, stopped when he felt there was too much resistance against the blade and tried again. Soon he was all the way round, and he was able to pull out the saw. There was no evidence of tearing in the membrane beneath. He paused before proceeding. He was finding this tough. Even though he d swigged down some of Irgen s own super-mixture before the operation: a paper cup filled with equal quantities of coffee and undiluted blackcurrant squash. A lot of caffeine. A lot of sugar. He had to smile. He was beginning to feel calmer, and the thumping of his heart in his chest was no longer as uncomfortable; rather it heightened his concentration. He put his fingers on the slice-shaped bone flap, and lifted it gently. By scraping the underside carefully with a periosteal raspatory he loosened the connective tissue that held it down. He was soon able to place the bone flap in Edith s hands. She took it like a newborn child, wrapped it in damp swabs and laid it in a metal dish filled with water on the instrument table. Yes, he was feeling calmer. But the danger wasn t over yet. Now he had reached the brain itself, and it was now that he could cause irreparable damage if he made a mistake. Dura knife.

4 Almost before he d said it, he felt the instrument placed in his hand. Edith was always a step ahead. Even now, in the middle of the night, she was on her toes, leaning over him, with the eyes and the reactions of a hawk. Not all operating nurses were like that. Which was possibly why a word, rarely used in theatre, slipped out of him now: Thank you. You re welcome. Her answer was swift, and did not invite further conversation. Mathias placed the blade on the surface of the brain membrane and pressed it in. The instant it was through, a thin liquid, the colour of cough medicine, started to seep out of the little cut. There was no doubt that he had come in where the blood was accumulating. Scissors and surgical tweezers. Again his command felt completely unnecessary. The knife had already been removed from his grip. Soon he felt the scissors between his fingers, but Edith s voice made him look up. Give me the suction and you ll get your tweezers. Of course. His left hand wasn t free. He let her take the suction wand and left his hand suspended in mid-air until the tweezers lay between his fingers. Their eyes met for a moment, before Edith looked down at the operating area and positioned the suction at the incision in the brain membrane. And no more thank yous, please, she said, before he could open his mouth to say anything. We should keep that for later. Mathias didn t answer. He knew she was right. As always. The coagulated blood reminded Mathias of red port jelly. He lowered the end of the suction wand diagonally down towards the area of bleeding. Edith had already begun to spray water over the red mass, some of which responded by slithering to the sides, some by dissolving. He asked to be given a spray himself and together they worked patiently; spraying and sucking. Soon the brain before them was naked and virginal. It must be like this to land on another planet. Among the creases and folds were fat, purple coloured, wormlike veins with long white strings of spiderweb-like arachnoid membrane. By contrast the arteries were neater and almost pink in colour where they coiled themselves like slippery fish over the sand coloured landscape. It s pulsating here, Edith exclaimed. That s a good sign. Mathias reached out for the biopsy forceps on the instrument table and helped collect the blood clots. Edith was right. The pulse from the heart was making the brain rise in fits and starts, which meant that the brain was getting enough blood and there was a fair chance it hadn t suffered too much damage. Yes, it was going to be alright. The pressure on the brain had been removed, and the biggest part of the job was over. All he had to do now was to fill it well with water, before closing the dura and replacing the bone flap. Or hold on a moment! He turned towards the screen on the wall where the CT scans were displayed. There was evidence of some traumatic injuries deep in the brain. In the worst-case scenario these could cause the brain to swell again, thereby leading to renewed problems with space in the cranium. We ll insert a pressure monitor, he said, noticing that she d stopped moving, as she stood over the instrument table tidying it up. She didn t need to say anything for him to know she disagreed. Shouldn t we bring the patient round? We ll put a pressure monitor in And no, we re not going to bring him round yet. Lohmann and Hasselgren aren t keen on pressure monitors. But I don t need to tell you that. Mathias pushed the bent needle through the brain membrane and tied the first knot. He knew what Edith was referring to. Lohman was particularly insistent that the patient s level of alertness was a more reliable control factor than any abstract pressure reading. The question was, whether he should let this affect his decision. He was about to pull the shorter knot thread to one side so Edith could cut it, but she had the scissors poised before he got there. Now she took the

5 new thread and pulled it under the area until it was tight. She had already understood that he was going to do a continuous suture, wonderful Edith. The boy could be on the respirator, stay under observation and wake up slowly with a monitor inserted to follow any changes of pressure in the cranium. It might be over cautious, but it was better than taking a risk. We re putting a pressure monitor in, he repeated. Edith turned to her unsterilised colleague, who sat leaned against the wall, nodding off. Dr Grande wants a pressure monitor. Can you organise that? The nurse got up like a shot, as though an alarm clock had just gone off. Mathias watched as she scurried towards the door. On the door above her head he caught sight of the clock again. It showed that they were about to enter the day s seventh hour. His shift was soon over. God, he was tired. He lifted his shoulders. His muscles were stiff and sore, but deep inside he had a feeling he d not felt for a very, very long time. The fear that had been growing in him just a few hours ago, was now gone. Instead he was filled with an intense happiness. 2 Mathias Rain hammered against the dome window in the ceiling of the cell-like and window-less bedroom which was available to the neurosurgeon on call. Mathias put his bundle of papers on the table that was crammed in one corner, between the door and the wall. He was prepared for tomorrow s customary rituals. In half an hour the department s doctors would assemble in the x-ray department on the first floor to get an update on the last twenty-four hours of investigations. From there they would take the lift up to the meeting room on the eighth, and go through the condition of all the department s new admissions. Which was exactly why he had been up in the intensive care unit, NSICU, checking how much fluid had come into the drains of the patients up there, and talking to the nurses who had been on night duty. He had full overview. And not least: the CT scan taken of the young boy after the night s operation, showed that the blood had been successfully removed and that there was ample room in his cranium. It occurred to him that he might have been over zealous in inserting a pressure monitor after all, but it wasn t worth worrying about now. He was home and dry. And the outcome bore the sweet smell of success. He got undressed and went into the narrow bathroom where he turned the shower on and waited for the water to get hot. He was still high on the happiness he d felt towards the end of the operation. Perhaps he would ask to attend some operations after the morning meeting? The older surgeons on the department valued the display of such initiative. Mathias still remembered the remark made by the consultant, Odd Hasselgren, when he d made the mistake of complaining about the lack of follow-up given to junior doctors: There s no point moaning, Grande. If you want to learn something, you ll have to do a deal with your wife so she can look after the house and kids, and you can stay on after your shift and watch how your older colleagues do things. If you want to be a neurosurgeon you ll have to show some interest. Be a neurosurgeon. Of course that was what he wanted. So all he could do was nod compliantly when his boss, with his antiquated views on women, pontificated about how much he should contribute domestically. There was nothing for it, but to stick at it. Even of it was hard, he had survived this far in this position as a locum, which would soon run out. Whether or not he d be able to continue, he d still not been told, nor had he dared ask. He knew he had to secure a permanent training post to stay. Three such posts would be advertised in the coming autumn, and right now

6 he and two others were the only suitable candidates. Since the German, Werner Schlunk, already had a PhD, and the budding researcher, Thea Michelsen had a project on the go with a female professor, he was at the bottom of the list. But as long as he didn t do anything daft in the meantime, it would be alright. He d just stuck a hand into the shower and established that the water was at last luke warm, when he heard a very familiar noise. His pager. He could positively feel the stress hormones pumping into his veins. It was typical that his pager should go off just when he was trying to gather himself. He went back to the bedroom and dialled his call number. A woman s voice answered. Grande, on duty. Neurosurgery, he said into the receiver. The morning meeting s about to start. Can t it wait? Eh it s Ingrid from Intensive, I don t think so. Right. We ve having problems. Can you come? Right now? I m about to get into the shower. Is there something? It s your patient. We d rather you came as soon as you can. His ICP is sixty. Sixty? The word just bolted from his mouth. ICP. Intracranial pressure. It should be well under twenty. He turned towards the bathroom, saw the steam from the hot water drifting out into the bedroom. He d never felt less like taking a shower. He couldn t remember the last time he had run so fast. The stairs down to Reception disappeared beneath his feet. The long corridors to Intensive Care raced past like a DVD on fast forward. He d been attentive to haemostasis when he d closed the patient. Almost neurotically attentive. All the little blood vessels had been burnt off. There was nothing left that could start to pump blood into the cavity which he d cleared. Yet he knew that there could be no other explanation for such a high ICP reading. The pressure in the head would not have gone up so quickly if it hadn t begun to bleed again. Turning the last corner he saw somebody, presumably Ingrid, in front of the semi-circular reception desk at Intensive Care. He slowed and tried to gather himself. It might be too late to do anything. But if there was any doubt whatsoever, the patient had to go back on the table immediately. It was a matter of life or death. Nothing less. Still sixty? he said, catching his breath, as he came towards the nurse. But the expression on her face gave him the answer already. Sandemann is in there now. She s rung the CT Lab. They re ready, waiting for us. Yes, of course, Sandemann. He had to end up with Sandemann in charge at a moment like this. Every time he heard her name it reminded him of Kaptain Sabeltann. And it wasn t just because he d overdosed on the CD featuring this wicked pirate on the drive to the childminder s. Sandemann loved duelling with other surgeons whenever she could. Particularly if they were young and inexperienced. So it was a relief when he saw the consultant bent over the anaesthesia pumps as he entered the patient s room. It gave him a few seconds to brace himself. Mathias stood beside the bed and scrutinised the screen on the ICP monitor. It read 56mmHg. He glanced over to check that the lead was correctly fixed on the patient s head. He grabbed hold of the bedrails and tried to think. This wasn t good. He could already imagine the Senior Consultant, Mons Lohman, shaking his head at the forthcoming morning meeting. This junior doctor had taken something on which was beyond him. And now more experienced people would have to step into the rescue. He could forget the permanent training post. A dishonourable dismissal was what awaited him. Who are you? He looked up to find Karina Sandemann standing there staring at him.

7 Her face was pale, almost to point of being white, under her black hair. It wasn t just her name that reminded him of Kaptain Sabeltann. Mathias Grande, duty doctor on Neurology. Sandemann turned towards Ingrid who had taken a safe distance from the two duellists. When I tell you to page the duty doctor, I don t mean you to send me one of the young foot soldiers who act as switchboard ladies. I mean the surgeon. Mathias took a breath. I am the surgeon. Sandemann turned back to him, a glimmer of disdain in her eyes. So you re the person who s been at it tonight? Well, your patient s started to bleed. She nodded towards the ICP monitor. You ll have to come with me and whell the bed over to x-rays. How about informing your back up consultant? You certainly won t be taking charge of the reoperation yourself. This last remark made him look at the floor. No, he certainly wouldn t be entrusted with that. I ll ring, he mumbled. And there s a radiology report over there. Sandemann pointed to the end of the bed, You take care of that, and we ll ready to take him over there in a few minutes. Ingrid? Come and help me detach the machines. She beckoned to the nurse, who immediately scurried over. Mathias went to the table on which the report lay. He tapped his breast pocket, but realised he didn t have a pen. He took the sheet with him to the other side of the room where there was a desk with a telephone. He grabbed a pencil that was lying on the top of a pile of papers and began to write. ASDH. Operated in the night. ICP 60. Further haemorrhaging? He signed his name in the appropriate space, and turned towards Sandemann who was busy moving pumps and monitors over at the bed. He knew he should make that call, but couldn t bring himself to do it. This whole situation felt unreal. Everything had gone so well. Until now. He studied the naïve, weekend face of the young boy in the bed. Only the intubation tubes and the compress on his head indicated that anything was wrong. Without those you might think the boy was having the sweetest dreams. But with an ICP of sixty things looked bad. He d never come out of this without brain damage and permanent injury. If he made it at all, of course. Mathias lifted the receiver. There was nothing for it but to do what he was told. At least the boy s heart was still beating. His heart was giving a regular signal over on the screen. And his blood pressure wasn t too bad either. He lowered the receiver. A moment later he was across the room. The systolic blood pressure was under a hundred. It should have been higher to compensate for the higher intracranial pressure. The body would always try to ensure the brain was getting enough blood. Standing at the bed, he stretched out his hand and lifted both of the boy s eyelids simultaneously. The pupils were pin-sized. That meant that the third cranial nerve was not compressed. Could it be? What on earth are you doing? Sandemann had turned towards him. When was the rise in pressure noticed? What exactly do you think we do down here? Walk around wondering what we ll do if an alarm starts to ring? I wasn t thinking anything. I just wondered when the rise was noticed. When we changed monitors. It was Ingrid who chimed in. The other one fell on the floor in the transfer over here. We couldn t get a new one set up before we got him here. He swung round. A new monitor. The monitors had to be calibrated before being used.

8 He went back to the anesthesia chart and found the calibration number on the lead to the pressure monitor It was a shot in the dark, but he had nothing to lose. He looked up. Ingrid was standing by the ICP machine. Turn it off, he said, pointing over the bed. What? TURN IT OFF! She winced when he shouted, but did as he asked. Excuse me, Grande, have you gone out of your mind? Sandemann was walking towards him. Turn it on again! The ICP machine let out a long electronic groan, as Ingrid flicked the switch on again. This will have consequences, Grande, I can tell you. You hear me? The screen lit up neon blue. Again he saw the image of Mons Lohmann, his red pen striking his name wearily from the list of candidates for a permanent post. It was Ingrid s voice. It seemed bolder now. She had understood what he was getting at. Does it match with? He lowered his gaze towards the anesthesia chart, even though he already knew what it said. He had to be completely sure. No, 483. Can you? Shall do. He looked up again. Karina Sandemann was standing there with her hands at her side and chin jutting. There wasn t the slightest flicker in her pale face as, a moment later, the nurse exclaimed: 3 mmhg. The pressure s 3! My God, what a relief! I must have forgotten to calibrate it in the rush. The ripple of laughter that followed sounded like the ringing of bells. Mathias closed his eyes. This shift had certainly tested his metal. Thankfully it was soon over. He opened his eyes and walked towards the door. As he passed Karina Sandemann a song began to play in his head. Soon he was singing aloud too. Kaptein Sandemann is a dangerous man. The consultant looked anything but happy as she met his gaze. You think you can run the ship from here, then?